Background: In the clinical examination of patients with low back pain (LBP), musculoskeletal physiotherapists routinely assess lumbar spinal segmental motion by performing physical examination procedures such as observation of active range of motion and palpation of intervertebral motion. The validity of manual assessment of segmental motion, however, has not been adequately investigated.
Methods: In this pragmatic, multi-centre, criterion-related validity study, 138 consecutive patients with LBP were recruited and examined by physiotherapists with postgraduate training in musculoskeletal manual therapy. Clinicians examined each patient�s spine for the presence of segmental motion abnormalities, described as lumbar segmental rigidity (LSR) and lumbar segmental instability (LSI), then referred the patients for flexion-extension (FE) radiographs. The physical examination procedures of interest were: 1) assessment of forward-bending (FB) active range of motion (AROM); 2) FB and backward-bending (BB) passive physiological intervertebral motion testing (PPIVMs) in the sagittal plane; and 3) central postero-anterior passive accessory intervertebral motion testing (PAIVMs). Sagittal displacement kinematics of the lumbar spinal segments were measured from the FE radiographs, and served as the criterion standard against which the clinical assessment results were compared. The kinematic parameters measured were sagittal rotation, sagittal translation, ratio of translation per degree of rotation (TRR), instantaneous axis of rotation (IAR), and centre of reaction (CR). Reference ranges for normal motion were calculated from the analysis of FE radiographs of 30 asymptomatic volunteers. The accuracy and validity of the clinical examination procedures were then calculated, and reported as sensitivity, specificity, and likelihood ratios for a positive test (LR+) and a negative test (LR-).
Results: In patients with LBP, sagittal rotation LSR and sagittal translation LSR had a prevalence of approximately 5.7% (p <0.0005) in this cohort. Sagittal rotation LSI was not found in statistically significant numbers. Sagittal translation LSI was found at a prevalence of 3.6% (p <0.05). Abnormal TRR (23.3%), IAR (17.7%), and CR (16.5%) were more prevalent findings (all p <0.0005). Observation of the quantity of AROM, during FB, is not valid for the assessment of either total lumbar segmental sagittal rotation, or detection of individual segments with abnormal segmental motion. PPIVMs and PAIVMs are specific, but not sensitive, for the detection of rotation LSI and translation LSI. A positive test (grade 4 on a scale from 0 to 4) with BB PPIVMs may have some utility for the diagnosis of rotation LSI or translation LSI, with LR+ of 8.4 and 7.1 respectively (and 95% CIs from around 1.7 to 38). Likelihood ratio statistics for FB PPIVMs were not statistically significant. A positive test (grade 2 on a scale from 0 to 2) with PAIVMs may have some utility for the diagnosis of rotation LSI or translation LSI, with LR+ of 2.7 and 2.5 respectively (and 95% CIs from around 1.01 to 7.5). Neither PPIVMs nor PAIVMs were useful for the detection of LSR, or abnormal quality of motion as measured by TRR, CR, and IAR.
Conclusions: Abnormal spinal segmental motion is associated with the symptom of LBP, in patients presenting to physiotherapists with a new episode of recurrent or chronic LBP, however prevalence is low due to highly variable lumbar segmental motion among asymptomatic individuals. Manual physical examination has moderate validity, but limited utility on its own, for the detection of translation LSI. Further research should investigate the utility of other clinical examination findings for the detection of lumbar segmental mobility disorders.
| Identifer | oai:union.ndltd.org:ADTP/266156 |
| Date | January 2005 |
| Creators | Abbott, J. Haxby, n/a |
| Publisher | University of Otago. Department of Anatomy & Structural Biology |
| Source Sets | Australiasian Digital Theses Program |
| Language | English |
| Detected Language | English |
| Rights | http://policy01.otago.ac.nz/policies/FMPro?-db=policies.fm&-format=viewpolicy.html&-lay=viewpolicy&-sortfield=Title&Type=Academic&-recid=33025&-find), Copyright J. Haxby Abbott |
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